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Section 43 • Haryana Civil Services (Compassionate Financial Assistance or Appointment) Rules, 2019

43. Repeal and Savings.

Form CFA-1
Form CFA-1
(see rule 5 and 36)
Application for Compassionate Financial
Assistance
Application for Compassionate Financial
Assistance
1
Name :
2
Date of Birth :
3
Date of joining on regular basis of deceased
employee/disappeared Government employee:
4
Date of death/disappearance alongwith copy of
death certificate or First Information Report (FIR)
5
Designation/Post last held :
6
Last drawn Basic Pay :
Full information of Family Member eligible
for compassionate financial assistance :
Full information of Family Member eligible
for compassionate financial assistance :
Paste passport size attested photo of family
member eligible for compassionate financial assistance
7
Name :
8
Permanent Address :
9
Corresponding Address :
10
Relation with the deceased/disappeared
Government employee :
11
Branch of concerned Department at Tehsil or
District Level selected for payment of compassionate financial
assistance.
12
Name of the Bank
Bank Account No.
IFSC Code
Branch Address
13
Detailed information regarding dependents of
deceased/disappeared Government employee
Serial Number
Serial Number
Name
Name
Relation
Relation
Date of Birth
Date of Birth
Proof of Date of Birth
Proof of Date of Birth
Monthly Income from any source
Monthly Income from any source
Married/ Unmarried
Married/ Unmarried
Aadhar No.
Aadhar No.
1.
2.
3.
4.
5.
14
Any other information
Place:
Date:
Signature of the applicant
To be furnished by the Head of Office
To be furnished by the Head of Office
Comments regarding
eligibility of compassionate financial assistance:
Place
Date
Signature of the Head Office
Form CFA-2
Form CFA-2
( see rule 7)
Application form for compassionate appointment
Application form for compassionate appointment
1.
Name of the deceased/missing Government
employee:
2.
Date of birth of deceased/missing Government
employee:
3.
Date of joining of deceased/missing Government
employee:
4.
Date of death of deceased Government employee
(with proof):
5.
Date of missing employee (with proof):
6.
Information of the applicant :
(a)
Name :
(b)
Address :
(c)
Relation with the deceased/missing Government
employee:
(d)
Whether fully dependent on the deceased/ missing
Government employee? If yes, proof thereof:
(e)
Source of income:
(f)
Whether employed or unemployed ?
(g)
If employed in any Department or Organization
under any State Government or Government of India, name of the
office and Basic Pay.
(h)
Whether suffering from any chronic disease or
physically handicapped ?
7.
Information about the dependents of the
deceased/missing Government employee: -
Name
Age
Full address (if in service name of office)
Income/ Details of Government/ private service
Monthly Income
Details of movable/ immovable property and
monthly income thereof
Any other information
1
2
3
4
5
6
7
(a)
Widow/Husband
(b)
Son (unmarried)
(c)
Unmarried daughters
(d)
Mother/Father dependent on the deceased/missing
Government employee.
8.
General Financial position of the family (this
information is to be given in affidavit proforma.).
9.
Member of the deceased/missing Government
employee's family who opts for Government service. His
educational qualifications and other information.
10.
Any another related information, if any.
11.
If the job is given under the scheme, an
affidavit is to be enclosed by other family members that they
shall not claim further appointment under this scheme.
Place :______________
Signature of the applicant and address.
Date : ______________
Form CFA-3
Form CFA-3
( see rule-20)
Application for appointment under rule 20 for one of the dependent family member of Martyred Government employee.
Application for appointment under rule 20 for one of the dependent family member of Martyred Government employee.
1.
Name of Martyred :
2.
Department :
3.
Date of Martyr in certificate
4.
Full information of applicant
(i) Name
(ii) Full Address
(iii) Relation with Martyred
5.
Information of family of Martyred
Name
Name
Age
Age
Relation
Relation
Moveable/ Immovable Property
Moveable/ Immovable Property
Income
Income
Any other Information
Any other Information
6.
Educational Qualification and other
Information of dependent family member of Martyred and his wife/
dependent interested in Government service.
7.
If any employment under this scheme
is to be given to person other than wife then "no objection
certificate" from other dependent member is to be attached.
Date:________________
Signature of Applicant__________________
Full Address__________________________
Form CFA-4
Form CFA-4
( see rule 40)
Details of Family for Compassionate Financial Assistance or Appointment
Details of Family for Compassionate Financial Assistance or Appointment
Name of the Government employee
Designation
Date of birth
Date of appointment on regular basis
Details of the members of my family as on
Serial Number
Name of the member of family
Date of birth
Relationship with the Government employee
Monthly income, if any
Aadhar No
Remarks
1
2
3
4
5
6
7
1.
2.
3.
4.
5.
6.
7.
Place: __________________
Signature of Government employee
Dated : _________________
Countersigned
Signature of Head of office
(with date and stamp of Office)
Form CFA-5
Form CFA-5
( see rule 11)
Affidavit regarding Declaration
Affidavit regarding Declaration
(1) I shall maintain properly the other family members who were dependent on the deceased/missing Government employee mentioned in the form enclosed herewith and in case it is proved at any time that the said family members are being neglected or not being properly maintained by me, my appointment may be terminated.
(2) That the facts given by me above are, to the best of my knowledge, correct. If any of the facts herein mentioned are found to be incorrect or false at a future date, my services may be terminated.
Place: __________________
Deponent
Dated : _________________
Verification:
Place: __________________
Deponent
Dated : _________________
Form CFA-6
Form CFA-6
Indemnity Bond
Indemnity Bond
( see rule 31)
(To be furnished by the de facto guardian of minor eligible family member of deceased or missing Government employee)
1. ___________________________
2. ___________________________
1. ___________________________
2. ___________________________
Accepted for and on behalf of the Governor of Haryana by
___________________________________
(Name and designation of the Officer directed or authorized to accept the Bond for and on behalf of the Governor of Haryana)
1. ______________________________________________.
2. _______________________________________________
(Name and designation of witness)
Note 1. - (a) Full name of the claimant referred to as the 'Obligor'.
Note 1.
(b) State relationship of the Obligor to the deceased.
(c) Name of the deceased Government Officer.
(d) Full name or names of the sureties with name or names of the father(s)/husband(s) and place of residence.
(e) Designation of the officer responsible for payment.
Note 2. - The Obligor as well as the Sureties shall have attained majority so that the bond may have legal effect or force.
Note 2.
Indemnity Bond
Indemnity Bond
( See rule 34)
(To be furnished by the eligible family member in case of missing Government employee)
1. ___________________________
2. ___________________________
1. ___________________________
2. ___________________________
Accepted for and on behalf of the Governor of Haryana by
_____________________________________________________________________
(Name and designation of the Officer directed or authorized to accept the Bond for and on behalf of the Governor of Haryana)
1. ___________________________________
2. ____________________________________
(Name and designation of witness)
Note. - The Obligor as well as the Sureties shall have attained majority so that the bond may have legal effect or force.
Note.